GW1-2022-10256_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fin m can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES`
GARRETT CLYDE BANKS FROM 1'O DESCRIPTION
Well Contractor Name
ft. ft.
4519-A ft. ft.
VC'Well Contractor Certification Number 15.OUTER CASING for multi-cosed'wells)OR LINER'(ifli-licable FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 134 ft 6 1/4 #21 1 PVC
Company Name 16.iNNER CASING OR-TUBING eothermal'closed-loop)
21120112503 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. , in.
1-w all applicable well perni is(i.e.County,State. Variance,hyection,etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well•• FROM TO DIAMETERi SLOT SIZF. THICKNESS MATERIAL
❑Aricultural ❑Municipal/Public
ft. f. in.;
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single)
Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation t 0 ft. 20 ft. Bentoriite Pumped
Non-Water Supply Well:
ft. ft.
71Monitoring ❑Recovery
Injection Well:
❑Aquiler Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Ayuiter Storage and Recovery ❑Salinity Barrier ft. ft. I
❑Aquiler Test ❑Stornwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary).
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 34 ft OVER BURDEN
11-4-2022 34 ft 905 it GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location: ft. ttrA
Leland Marshall Howard ft. ft.
Facility/OwncrName Facility lD4(ifapplicable) ft. ft. NOV 1 1 2022
Green River Road Hendersonville, NC 28792Link
Physical Address,City,and Zip 21.REMARKS
Henderson 9553396711
C ountn Parcel Identification No.(PIN)
gib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
tit Bell field.one rat/long is sufficient)
N W 11-7-2022
Signature of Cern Well Contractor j Dale
6.Is(arc)the well(s): RPermanent or ❑Temporary Br signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gfthis record has been provided to the well owner.
11-ihi,is it repair.Jill wa known well consiraclion information and e-rplain the nalure of the
"pah wider 42/remarks section or on the hack of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
l ,,mwhiple injection or non-water supply wel/s ONLY with the saute construction,cou can
vthmit one jnrni. - SUBMITTAL INSTUCTIONS
9.'total well depth below land surface: 905 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l'or multiple wells list all depths i,'fdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
Dry Division of Water Resources,Information Processing Unit,
(ft.)
1i mare r level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:j In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: construction to the following:
I i.e.auger,rotary,cable.direct push,etc.)
Division of Water Resources,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C enter,Raleigh,NC 27699-1636
13a.Yield(gym) 0 Method of test:
RIG 24c.For Water Supply&Injection Wells:Also submit one copy of this fortm within 30 days of completion of
131).Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Fore;GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013